Attachement 3


FEB-02-2004 MON 05:56 PM US-DFPT/LABOR EEOICP/DEN FAX NO, 7202643217 P, 02

Department of Energy \]
National Nuclear Security Administration ‘, fh aS
Service Center

Tuly 25, 2003

Claims Examiner, a f Department of Labor

Employment Standards Administration

Bnergy Employees Occupational Mness Compensation
P.O. Box 46550

Denver, CO 80201-6550

Qe

Per your request dated July 7, 2003, item 3, there was a contract between the Department of
Energy and Ross Aviation, Inc, (Contract No. DE-AC04-89AL5231 8), The Period of
Performance of the Contract was March 1, 1989 through February 29, 1996.

If you have any questions concerning the information provided, please contact me at $05-845-6108
or Linda L. Sanchez at 505-845-4319.

Sincerely,
Bly K. Ghege
Philip R. Griego

Property and M&O Contract Support Department

ae rene a oan

sme ee re BS nae
ih | AR aha
Absargarg, NM ENON 000 Intapondancen Aseria, BN CV etssae Shee


FEB-02-2004 MON 06:59 PM US-DEPT/' ABOR EEOICP/DEN FAX NO, 7299742917 P, 03/04

EMPLOYMEK_/i_iFICATION SHEET

This form is used to verify the employment history of an em
{iinees Compensation Program Act of 2000 (EEQICPA), Thi

Deparment of Energy. All atlached documentation (EE-4
to completion.
F Se

ployee namad In a clair for compensation under the Energy Employees Occupational
© employment verifloation and certification must be completed by an official of the
or BE-2 Claim for Benefits and EE-3 Employment History) should be reviewed prior

TATE Bouin eae ua a Mua

co ce

fopriate response. If the employee worked for multiple empioyers af the facility,
istrict office handling the claim of make a Copy of a blank sheet.

You must select ONE of the foilowing three options and provide the appi
you may request additional Employment Verification Sheats from the dit

El OPTION 1~ veririen emecoyment

~ Verified Perlod-t | From 35 “Tt oh +t bogation OMSmployment-Activitien, itenewn (Building, Laboratory, aie Mine sete

O1D0E employee Fagactor Di suvcontractor Department of Energy Facility @ Hangar 481, KAFB, NM
Veritied Portod 2| From to Location of Employment Activities, ff known (Bullding, Laboratory, Site, Mine, sto.)

TAD0E employes — CI contractor Q subcontractor

Verified Period 3] From to Location of Employment Activities, it known (Building, Laboratory, Site, Mine, etc.)

EIDOE employee — L] Contractor Di suncontractor

Verified Period 4|From to . Location of Employment Activities, if known (Building, Laboratory, Site, Mine, eto.)

OO0E employes — LA Contractor Chsubcontractor |

0 OPTION 2— no verirication ts POSSIBLE, BUT OTHER PERTINENT EVIDENCE EXISTS -aeeers

The Deparment of Energy has conducted a reasonable se:
‘employment, However, evidence has been identified that
all that apply and attach pertinent documentation to this t

arch of avallable records and is unable to verify the accuracy of the claimed doticot

may assist the DOL, olaims examiner reach a determination of covered

emproyitent Check =.
form. if needed, a narrative statemant can be Prepared to summarize findings or
provide claritication. voeey
a Security Clearance OL Medicar Health Records veetee seer
a=5 Proof of Contractual or Subcontractual Relationship ~~ Employee {1D Badge . ~ . .
Dosimeter Badge Number: “~~ Mie Eo others ina nn ae

‘D) OPTION 3=no evioetice Exists IN REGARD TO THE CLAIMED EMPLOYMENY

The Oepartment of Energy has conducted @ reasonable Search of available records and ia unable to Ideniity any evidence that can be used to either
concur or disagree with the aocuracy of clalmed Cinployment. Furthermore, no documentation of other evidence Nas been Identified that could assist
the Department of Labor in ‘Making @ dejermination of covered employment,

igning this employment sheet, the Department of Ene
‘the information provided on this sheot accurately reflects

ne
form, the Department of Fnaray anknnudarnae tease a=

y 1s acknowledging that has conducted a Teasonable search of available records and that
Fesults of that search, For any Porlod of claimed employment that is not verified by this
“ t disagree with the accuracy of claimed emolovment

>rint Name, Talanhona Na-

Address

becember 23, 2003

ipa EE-S Employment Verification
Attachment 6


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Iliness Gompensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Appendix — Petitioner 3

Use of this form and disclosure of Social Security Number are voluntary. Failure to use. this form or di
this number will not result in the denial of any right, benefit, or privilege to which you may be enti

e-

Use this Appendix for Petitioner 3.

This appendix form is to be used as needed. Petitioner 3, or his or her representative, should complete the
parts applicable to him or her.

Refer to the Generat Instructions on completing petitioner information for Parts A, B, or C.

If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

Except for signatures, please PRINT all information clearly and neatly on the form.

O An Energy Employee (current or former), Start at C
If you are:} 1 A Survivor (of a former Energy Employee), Start at B
QA Representative (of a current or former Energy Employee), Start at A

A_ Representative Information — Complete Section A if you are authorized by an Employee or

Survivor(s) to petition on behalf of a class.

A. Are you a contact person for an organization? 0 Yes (Go to A.2) Q No (Goto A.3)
A.2 Organization Information:

Name of Organization

Position of Contact Person
A.3 Name of Petition Representative:

Mr./Mrs./Ms. First Name Middle Initial Last Name
A4 Address:
Street Apt # P.O. Box
* City” State . Zip Code
A.5 Telephone Number: ( )

A6 Email Address:

A.7 Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization
form for this purpose is provided.

If you are representing a Survivor, go to Part B; if you are representing an Employee, go to Part C :

Name or Social Security Number of First Petitioner: __



Attachment 1

I was an employee of Ross Aviation for many years. started
working for Ross Aviation after the date that J first went to work tor the company. I recall
that she worked as a secretary in an office that was located in ihe hanger building that
Ross occupied on Kirtland Air Force Base. Kirtland Air Force Base is located in
Albuquerque, New Mexico. During the years that worked for Ross Aviation I
would see her on occasion working in her office, that was known as the library room. I
would also see her on occasion walking through the portion of the building where
airplanes were parked and on occasion I would see her working in other administrative
office rooms within the hanger building.

During the time th: worked for Ross Aviation, company airplanes that
included large airplanes sucn as wasn 7s and DC 9s, would be cleaned in the hangar
building, and outside of the hanger building, as well. On some occasions Ross Aviation
airplanes would be taxied onto Sandia National Laboratories, facility to be loaded. On
other occasions cargo would be brought from the Sandia National Laboratory facility to
an area known as “the ramp” near to the Ross Aviation hanger. The cargo would then be
loaded into Ross Aviation airplanes while the airplanes were parked on the ramp. I do not
know of what the cargo consisted. On some occasions when cargo would be loaded into
planes that were parked on the ramp, security guards would be present. I addition I recall
that pilots, flight engineers and flight mechanics who were present at the time of loading
on the ramp would be wearing radiation dose badges. I was not required to wear radiation
badges during times that I assisted in loading cargo into the planes, or while cleaning the
planes. ould have been working in the offices in the hanger building on
occasions when planes were cleaned in the hanger building, and on occasions when cargo
would have been loaded into airplanes parked on the ramp that was located near to the
Ross Aviation hanger.


Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B

Survivor Information — Complete Section

B.1. Name of Survivor:

iv
B.2 Social Security Number of Survivor:
B.3 Address of Survivor:

Bw. 1 noL ENG Lest vaniie

Street Ant # PO Ray

City State Zip Code
B.4 Telephone Number of Survivor:
B.5 Email Address of Survivor:

B.6 Relationship to Employee: Spouse Son/Daughter arent
Grandparent Grandchild
GotoPartC.. ~  *-

Employee Information — Complete Section C UNLESS you are a labor organizati
C.1. Name of Emolovee:

Mc/Mrs/Ms. First Name Middie tnitial “= Last Name
C.2 Former Name of Employee (e.g., maiden name/legal name change/other):
Montano
Mr./Mrs./Ms. First Name Middle Initial Last Name

C.3 Social Security Number of Employee:
C.4 Address of Emplovee (if livina):

Cteant es Xo 0-7
ca SM SMA Zip Code he
C.5 Telephone Number of Employee: ( ) -_ N/A
C.6 Email Address of Employee: N/A

C.7 Employment Information Related to Petition:
C.7a Employee Number (if known):

C.7b Dates of Employment: Start _ 1985 End 1994
C.7c Employer Name: Ross Aviation Inc.

C.7d Work Site Location: Hangar 481, KAFB, NM
Adjacant_to Sandia National Laboratory

C.7e Supervisor's Name:

Go to Part E.

Name or Social Security Number of First Petitioner: _




imployment History Affidavit, re > U.S. Depart “nt © ibor

Inder the Energy Employees ~ccupational Employment Standards Administration cS

lIness Compensation Program Act Office of Workers Compensation Programs
Expiration Date: 7/31/2004

Note: This form is used to affirm the employment history of a living or deceased individual who incurred a OMB No. 1245-0197
designated illness as a result of their exposure to radiation, beryllium, or silica while in the performance of
duty for the Department of Energy and certain of its vendors, contractors, and subcontractors, PROVIDE
RESPONSE IN SHADED AREAS. Disclosure of a social security number is voluntary. Failure to disclose
this number will not result in the denial of any right, benefit or privilege to which you may be entitled.

a.) Print Full Name

b.) Street Address
Mailing Address I

¢c.) City, State, Zip Code

a.) Print Full Name

b.) Maiden/Former Name

c.) Social Security Number
(Optional)

In chronological order, starting with the most recent period of employment, describe your knowledge of the employment
history of the person named In item 2a. Provide as much identifying information as possible concerning the name and

location of the employer.

Dates of Employment Start Date / / End Date / /
Employer name and See Attachment 1, the terms of which are hereby incorporated by
work site location reference.
Describe the type of See attachment 1, the terms of which are hereby incorporated by
work performed reference.
Explain how you know the See Attachment 1, the terms of which are hereby incorporated by
person named in 2a worked for | -aference.
this employer
Form BE-4
May 2001

Attachment 8


Attachement 5



This form is used to affirm the employment history of a living or deceased energy employee. The EE-4 is an acceptable
format for providing an affidavit in support of an otherwise unsupported work history and can be filled out by anyone with
knowledge of a covered employee's work history. Use as many EE-4 forms as needed. If you require additional space to
provide comments, attach a signed supplemental statement.

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy
Employees Occupational I!Iness Compensation Program Act (P.L. 106-398) (EEOICPA) Is administered by the Office of
Workers’ Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on
claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for, and the
amount of, benefits payable under the EEOICPA, and may be verified through computer matches or other appropriate
means. (3) Information may be given to the Federal agencies or private entities which employed the claimant at the time
of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to
consider other relevant matters. (4) Information may be disclosed to physicians and other health care providers for use in
providing treatment or medical rehabilitation, making evaluations for the Office and for other purposes related to the
medical management of the claim. (5) Information may be given to Federal, state, and local agencies for law enforcement
purposes, to obtain information relevant to a decision under the EEOICPA, to determine whether benefits are being paid
properly, including whether prohibited payments have been made, and, where appropriate, to pursue salary/administrative
offset and debt collections actions required or permitted by the Debt Collection Act. (6) Failure to disclose all requested
information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision. This
notice applies to all forms requesting information that you might receive from the Office in connection with the processing
and adjudication of the claim you filed under the EEOICPA.

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering data needed, and completing and reviewing the
collection of information. If you.have any comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, sent them to the Office of Workers’ Compensation Programs,
U.S. Department of Labor, Room $3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. Do not submit the
completed claim to this address. Completed claims are to be submitted to the appropriate regional District Office of
Workers’ Compensation Programs. Persons are not required to respond to this information collection unless it displays a
currently valid OMB number.

Form EE-4
May 2001



Attachement 7



[Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

" A OMB Number: 0920-0639 Expires: 07/31/2010
Petitioner Authorization Form Page 1 of 2

Use of this form is voluritary. Failure to use this form: will not result in the denial of any right ; benefit,

instructions:

If you wish to petition HHS to consider adding a class of employees to the Special Exposure Cohort and you
are NOT either a member of that class, a survivor of a member of that class, or a labor organization
representing or having represented members of that class, then 42 CFR Part 83, Section 83.7(c) requires
that you obtain written authorization. You can obtain such authorization from either an employee who is a
member of the class or a survivor of such an employee. You may use this form to obtain such authorization
and submit the completed form to NIOSH with the related petition. Please print legibly.

For Further Information: If you have questions about these instructions, please call the following NIOSH

toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
Support about an SEC petition: 1-800-356-4674.

Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Employees for

Addition to the Special Exposure Cohort

Name of Class Member or Survivor

Straat Addrace af Clase Member or Suirvivar Ant # P.O. Box

City, State, Zip Code of Class Member or Survivor

do herehv authorize:

Name of Petitioner

Address of Petitioner. Apt. # P.O. Box

City, State and Zip Code of Petitioner

to petition the Department of Health and Human Services on behalf of a class of F employees

that inclu:
Name of C ree’s survivor)
for the adv... -. we Lene ew we ope =e: —-- JSure Cohort, under the Energy Employee's

Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385).

In providing this authorization, | recognize that the petitioner named above will have all the rights
ofé ‘

2 fey log?

Sig Date

Name or Social Security Number of First Petitioner:


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

- OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Page 7 of 7

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 300 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.
Persons are not required to respond to the information collected on this form unless it displays a currently
valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the
following:

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEOQICPA authorizes HHS to implement its responsibilities with the
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional
classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEOICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed
below.

NIOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal
agencies, other government or private entities and to private sector employers to permit these entities to
retrieve recurds requited by NIOSH; (b) identified -witnesses-as-designatéed by NIOSH se.thattkeses=.
individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a
Congressional staff member in response to a verified inquiry.

eee oe

This notice applies to all forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these
forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to
provide required information may not be considered by HHS.

Name or Social Security Number of First Petitioner: _




Ross.Aviation, Inc.
Albuquerque, New Mexico
end



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B
_--.__Proposed _Definition_of Employee Class. Covered by Petition — Complete Section E.

E.1 Name of DOE or AWE Facility: Ross Aviation Inc.

E.2 Locations 7 the Facility relevant to this petition:
Hangar building, offices, hallways, Storage areas, ramp, tarmac

adjacant to building; areas within & adjacant to building where shipments
were delivered & loaded on planes.

Page 4 of 7

E.3 List job titles and/or job duties of employees included in the class. In addition, you can list by
name any individuals other than petitioners identified on this form who you believe should be
included in this class:

E.4 Employment Dates relevant to this petition:

Start 1989 End 1994
Start End
Start End
E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: O Yes Q No

If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages
as necessary):

Name or Social Security Number of First Petitioner: __


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Itiness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B Page 3 of 7
Labor Organization Information you are a labor organiz:

D.1. Labor Organization Information:

Name of Organization

Position of Contact Person
D.2 Name of Petition Representative:

D.3 Address of Petition Representative:

Street Apt # P.O. Box

City State Zip Code
D.4 Telephone Number of Petition Representative: (_ )
D.5 Email Address of Petition Representative:

D.6 Period during which labor organization represented employees covered by this petition
(please attach documentation): Start End

D.7 Identity of other fabor organizations that may represent or have represented this class of
employees (if known):

Go to Part E.

Name or Social Security Number of First Petitioner: _



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Contro! and Prevention
illness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Petitioner Authorization Form Page 2 of 2

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 3 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions,
Persons are not required to respond to the information collected on this form unless it displays a currently
valid OMB number.

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit, or
privilege to which you may be entitled.

Name or Social Security Number of First Petitioner:


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Page 6 of 7

F.3. QO We have attached a report from a health physicist or other individual with expertise in
tadiation dose reconstruction documenting the limitations of existing DOE or AWE records on
radiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.

(Attach report to the back of the petition form.)

F.4. Q IMWehave attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a tack
of monitoring or the destruction or loss of records) for estimating the radiation doses of
employees covered by the petition.

_faitach report to the back of the Petition form.)
: Go 'to'Part G.

Signature of Person(s) Submitting this Peti — Complete Section G.

inn A wanwinasinn af thuee persons may Sign the petition.
Z2/z
Date

ot] ey} 2004

Date

Signature Date

Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of
fact or any other act of fraud to obtain compensation as provided under EEOICPA or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both. | affirm that the information
provided on this form is accurate and true.

Send this form to: SEC Petition —
fh ge Office of Compensation Analysis ahd-<Support'« -
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

If there are additional petitioners, they must complete the ‘Appendix Forms for additional petitioners.
The Appendix forms are located at! the end.of this document,

Name or Social Security Number of First Petitioner: ___


Attachement 4



02-27-09 PO2:44 IN

February 24, 2009

SEC Petition

Office of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Re:

Dear Sir or Madam:

Enclosed please find a special exposure court petition that we are submitting on behalf of our
client/petitione

In support of this petition we enclose items as follows:

1) Special exposure cohort petition-form B;

2) Petitioner authorization form designatin to serve as a petitioner on behalf
ol

3) Photocopy of affidavit by 4

4) Photocopy of death certificate of

5) Photocopy of marriage certificate confirming marriage o: ind petitioner

6) Employment records of! ncluding identification badge, Ross Aviation Inc.
totter ot roocmmendation dated Junc 3€, 1904, resume, ond tettcr ot rccommendation ty 7
Fernandez Co. LTD ;

7) Employment records verification by Ross Aviation and

8) U.S. Department of Labor Employment Standards Administration letter of July 25, 2003
documenting the existence of a contract between the Department of Energy and Ross Aviation.

Petitioner contends that contracted pancreatic cancer and that exposure to radiation
and radioactive substances during her employment at Hangar 481 with Ross Aviation Inc. was a
significant factor in causing the on set of that cancer which lead to her death on September 22, 2000.
Petitioner also contends that a special exposure cohort should be recognized for Hangar 481 during
the term of covered employment because radiation exposures and radiation
doses potentially incurred by members of the proposed class were not monitored, either through


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
MIness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Appendix — Petitioner 2

Use of this form and disclosure of Social Security Number are voluritary. Failure to.use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitled. -:

Use this Appendix for Petitioner 2.

This appendix form is to be used as needed. Petitioner 2, or his or her representative, should complete the
parts applicable to him or her.

Refer to the General Instructions on completing petitioner information for Parts A, B, or C.

If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

Except for signatures, please PRINT all information clearly and neatly on the form.

O An Energy Employee (current or former), Start at C

If you are: | A Survivor (of a former Energy Employee), Start at B

@ A Representative (of a current or former Energy Employee), Start at A

A_ Representative Information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behalf of a class.

Are you a contact person for an organization? Q Yes (Go to A.2) © No (Go to A.3)

A.2. Ornanization information:

Nanie Ul Urgamnizauurr

Position of Contact Person
A.3 Name of Petition Representative:

WIL OWaIO, oF HOC NNCT Wangan te ee eee

A4 = Addrace:

Street Apt # P.O. Box

aon Sere

City” , 7 Chote : 7 Code
A5 Telephone Number:
A6 Email Address:

A.7 _@ Check the box at teft to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization
form for this purpose is provided.

If you are representing a Survivor, go to Part B; if you aré representing an Employee, go to Pait C;

Name or Social Security Number of First Petitioner:


This page left intentionally blank.



Job Objective:
Position Desired:

Skills:

Experience:
CLERK/RECEPTIONIST (Gulf Laying Off - Lateral Transfer)
Gulf Mineral Resources Co., P.O. Box 1150, Grants, NM 87020.

Specific Duties:

SOTED:

rific Duties:

sesnondence (ce
vering the
1 appoint-
spplicants

2S, order-


Ross Aviation, Inc.

June 30, 1994

To whom it may concern:

I wish to recommend I have worked with her for
over eight years during which I have found her to be a self
starting, hard working individual willing to learn new taske:
always ready to upgrade her skills even on her own time.
accomplishes all these things always with a pleasant accacuuc
toward her clients, co-workers, and supervisors.

I know she would be an asset to your organization.

For further information, please call me at

Wn new sens ow Re eee ee cee eee



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Iiness Compensation Act National institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B Page 5 of 7

Basis for Proposing that Records and Information are Inadequate for Individual Dose —
Complete Section F.

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

Fil We have attached either documents or statements provided by affidavit that indicate that
tadiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area
monitoring.

(Attach documents and/or affidavits to the back of the petition form.)
Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that potential radiation eynosures were not monitored,
Emplovees of Ross Aviation, Including ee

whose affidavit is attached, did not wear dose monitoring
badges and to the best of my knowledge there was no monitoring of
any kind at Hangar 481 or adjacant there to. Shipments of substances
and items were delivered to the hangar in guarded shipments from
Sandia National] Labs and loaded into planes at Hangar 481 for
further delivery by personnel wearing dose badges.

F.2. O WWe have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the employees worked.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been fost, altered illegally, or destroyed.

Part F is continued on the following page.

Name or Social Security Number of First Petitioner:


Dates of Employment

Start Date

End Date

Employer name and
work site location

Describe the type of
work performed

Explain how you know the
person named in 2a worked for
this employer

Dates of Employment

Start Date

End Date

Employer name and
work site location

Describe the type of
work performed

Explain how you know the
person named in 2a worked for
this employer

Dates of Employment

Start Date

End Date

Employer name and
work site location

Describe the type of
work performed

Explain how you know the
person named in 2a worked for
this employer

5. Any person who knowingly makes any false statement, misrepresentation, concealment of fact or any other act
of fraud to obtain compensation as provided under the EEOICPA or who knowingly accepts compensation to which
that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may,
under appropriate criminal provisions, be punished by a fine or imprisonment or both. | affirm that the information
provided on this form is accurate and true.

Sig!

Form EE-4
May 2001


Attachement 8



FEB-02-2004 HON 05 196 PH US-DE PT/IABOR EEOICP/DEN = FAX NO, 7202649017

an!

U.S. DEPARTMENT OF LABOR Employment Standards Administration
Energy Employees Occupational Illness
Compensation
1999 Broadway Suite 1120

PO Box 46850
A Denver CO 80201-6550
720-264-3143

To: From: Karen Morman/US Department of Labor
Fax: Date: February 2, 2004

Phone Pages: 4, Including this page

Rei co:

Ourgent 1 For Review CO Please Comment 1 Please Reply 0 Please Recycle

*Gomments:

Per your request attached are the employment documents received from Ross Aviation. As t stated to you
on the phone they telephonically verified that 7 would never have provided a “service” on the
Sandia Laboratories site.

Also enclosed ts a copy of the contract that Ross Aviation had with the Department of Energy (DOE) for the
period —/89 through '96. You agreed that this would have been the only period that would _
have been working for Ross Aviation when there was @ contract in place with DOE. .

If you have any questions, please call me at 720-264-3143,

Attachment 7


1

ADDIACE DECADIN

S.

Turs


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Iliness Compensation Act National institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Page 1 of 7

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disciose
this number will not resuit in the deniai of any right, benefit, or privilege to-which you may be entitied. |

General Instructions on Completing this Form (complete instructions are available in a separate packet):
Except for signatures, please PRINT all information clearly and neatly on the form.

Please read each of Parts A — G in this form and complete the parts appropriate to you. If there is more
than one petitioner, then each petitioner should complete those sections of parts A ~ C of the form that apply
to them. Additional copies of the first two pages of this form are provided at the end of the form for this pur-
pose. A maximum of three petitioners is allowed.

if you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

if you have questions about the use of this form, please call the following NIOSH toll-free phone number and
request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition:
1-877-222-8570.

Q A Labor Organization, StartatD on Page 3

If you Q An Energy Employee (current or former), Start atC on Page2
are: & A Survivor (of a farmer Energy Employee), StartatB on Page 2
O A Representative (of a current or former Energy Employee), StartatA on Page 1

A_ Representative Information — Complete Section A if you are authorized by an Employee or

Survivor(s) to petition on behalf of a class.

A.1_ Are you a contact person for an organization? 1) Yes (Go to A.2) Q No (Go to A.3)
A.2 Organization Information:

Name of Organization

Position of Contact Person
A3 Name of Petition Representative:

OTN Sa aS Tiga OEE NTIS, I ete
A.4 Address:

Street Apt # P.O. Box

City State Zip Code

A5 — Telephone Number: (.)

A.6 Email Address:

A7 Q Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization

If.you are representing a Survivor, go to Part B; if you are representing an Employee, go to Part C.

Name or Social Security Number of First Petitioner


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Iiiness Compensation Act National Institute for Occupational Safety and Health

: OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Appendix — Petitioner 3

Survivor Information — Complete Section B if you are a Survivor of representing a Survivor.

B.1 Name of Survivor:

Mr/Mrs./Ms. First Name Middle Initial Last Name
B.2_ Social Security Number of Survivor:
B.3 Address of Survivor:

Street Apt # P.O. Box
City State Zip Code

B.4 Telephone Number of Survivor:  ( 2

B.5 Email Address of Survivor:

B.6 Relationship to Employee: Q Spouse Q Son/Daughter Q Parent

Q Grandparent Q Grandchild

Employee Information — Complete Section C.
C.1 Name of Employee:

Mr./Mrs./Ms. First Name Middle Initial Last Name
C.2 Former Name of Employee (e.g., maiden name/legal name change/other):

Mr/Mrs./Ms. First Name Middle Initiat Last Name
C.3 Social Security Number of Employee:
C.4 Address of Employee (if living):

Street Apt # P.O, Box

City. ; . . State. = ee.

e—
C.5 Telephone Number of Employee: )
C.6 Email Address of Employee:

C.7 Employment information Related to Petition:
C.7a Employee Number (if known):

C.7b Dates of Employment: Start End
C.7c Employer Name:
C.7d Work Site Location:

C.7e Supervisor's Name:

Sign Part G of the original petition. — 2

Name or Social Security Number of First Petitione:


Attachement 2


Attachement 1


oe
ee

FEB-02-2004 MON 06:00 PH US-DEPTM/' “BOR EEOICP/DEN FAK No, TPPOOBAINT

Ross Aviation, Inc,
Decomber 23, 2003

US Department of Labor

Energy Employees Occupational Injury Compensation
1999 Broadway Suite 1120

PO Box 46550

Denver, CO 8020)-6550

As pet your teleohone conversation on Decomber 23, 2003 with my assistant, this letter is
to verify that worked for Ross Aviation, Inc. located at Hanger 481,

Kirtland Air Force Base, New Mexico. Ross Aviation is not in any way affiliated wrtr- - +

Sandia National Laboratories nor did work at Sandia Laboratories facility
while employed with Ross Aviation. . ra

P, 04/04



AT hannarcnia

sachs

{
“mai oO} 3[sue pe ploy ly al

sh

feULIS} EAN eros

qe ue su

eyo JuaUMOOH sIyI JO
"

ecconsecth

sal

yorq 34,

oN

nasi by.aln' A

nua

| etoxsesena:



SEC Petition
NIOSH

February 24, 2009
Page 2.

personal monitoring or through area monitoring or to the best of the knowledge information and
belief of the petitioner.

If you have any questions or need additional information please let us know.




Attachement 6



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
{IIness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010
Special Exposure Cohort Petition — Form B Appendix — Petitioner 2

Survivor Information — Complete Section B if you are a Survivor or representing a Survivor.

B.1. Name of Survivor:

MravirsviMs. First Name Wwilagie initial Last Name

B.2. Social Security Number of Survivor: .
B.3. Addraee of Survivar:

Ctraat Ant# PO. Box

City State Zip Code
B.4__ Telephone Number of Survivor: _
B.5 Email Address of Survivor:
B.6 Relationship to Employee: Spouse Son/Daughter Parent
Grandparent Grandchild

Employee Information — Complete Section C.

C.1 Name of Emplovee:

Mr/Mrs/Ms. First Name Middle Initial Last Name
C.2 Former Name of Employee (e.g., maiden name/legal name change/other):
Montano
Mr./Mrs./Ms. First Name Middle Initial Last Name

C.3 Social Security Number of Employee: _ oe
C.4 Address of Employee (if living):

N/A
Street Apt # P.O. Box
N/A
4--__Cily_. {home State phos eter en EID CODE nec ve See
C.5 Telephone Number of Employee: ( ) -N/A
C.6 Email Address of Employee: N/A

C.7__ Employment Information Related to Petition:
C.7a_ Employee Number (if known):

C.7b Dates of Employment: Start 1985 End 1994
C.7c Employer Name: Ross Aviation, Inc.
C.7d Work Site Location: _Hangar 481, KAFB, NM

Adjacant to Sandia Nationa] Labortary

C.7e Supervisor's Name:

_Sign Part G:of the original petition, :

Name or Social Security Number of First Petitioner:


Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
Miness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2010

Special Exposure Cohort Petition — Form B Appendix — Continuation Page
Continuation Page — Photocopy and complete as necessary.

: : 7 : Attach to Form B if necessaty.

Name or Social Security Number of First Petitioner: __